05 SEP 2008 _______________________________________ *AAIB Says Ice In Fuel Likely Caused BA 777 Accident At Heathrow *Airline safety review after BA Heathrow crash *Remains of 17 killed in DRC plane crash found *EU authorities seek to promote air safety *FAA Adds ADS-B Equipment In South Florida **************************************** AAIB Says Ice In Fuel Likely Caused BA 777 Accident At Heathrow Recommends Operators Of Type Cycle Throttles In Flight British investigators are reasonably certain ice crystals blocked fuel lines on a British Airways airliner that landed short of the runway at London's Heathrow Airport in January. As ANN reported, the Boeing 777-200ER was on an extended final to land at Heathrow on January 17, when the plane's autopilot commanded the 777's engines to spool up. Both engines responded initially... but thrust then dialed back to just above flight idle -- first in the right turbofan, then the plane's left engine. The plane's flight crew was later heralded for bringing the plane down safely, landing short of the threshold to Runway 27L at Heathrow. Only relatively minor injuries were reported to some of the plane's 136 passengers and 16 crew. Investigators quickly ruled out a systems failure on the 777, or in its Rolls-Royce Trent 800 turbofans... and the airliner had plenty of fuel left after what had been an uneventful flight from Beijing, China. Officials then narrowed their search, looking for kind of problem with the plane's fuel. The Air Accidents Investigation Branch determined the plane flew through unusually cold air over Siberia... and investigated the possibility the plane's fuel could have been affected. On Thursday, the AAIB said they've ruled that out... adding they now believe a larger-than-normal amount of water contained in the fuel froze, and the resulting ice crystals blocked the fuel lines as they melted while the 777 descended to land. Officials theorize the amount of water was enough to overwhelm the Fuel Oil Heat Exchangers on both engines, which are designed to melt ice crystals and vaporize the water. The AAIB also recommended all 777 operators periodically increase engine thrust levels while operating in the flight levels... a time when engine power is usually reduced to low-levels, which may allow excessive ice to form. The National Transportation Safety Board heralded the AAIB's report Thursday, stating the investigation was assisted by a US team that included NTSB specialists, the Federal Aviation Administration, and Boeing. "When it comes to aviation safety, there are shared interests that transcend national borders," said NTSB Chairman Mark Rosenker, adding the Board has issued a recommendation to the FAA and EASA to consider the implications the AAIB's findings may have on the 777, and other airliners. aero-news.net *************** Airline safety review after BA Heathrow crash Airline safety is to be reviewed after the Air Accidents Investigation Branch found that a build up of ice in the fuel supply was probably the cause of the BA crash at Heathrow in January. The AAIB has made three urgent safety recommendations following its initial report into the Heathrow crash. The first calls for interim measures to be introduced for the plane and engine in question - a Boeing 777 powered by Rolls Royce Trent 800 engines - "to reduce the risk of ice formed from water in aviation turbine fuel causing a restriction in the fuel feed system". But the second recommendation is that immediate action should also be taken to consider whether a similar problem could also occur with other aircraft and engine combinations. In its final safety recommendation, the AAIB calls for the European Aviation Safety Agency and the Federal Aviation Adminstration to "review the current certification requirements to ensure that aircraft and engine fuel systems are tolerant to the potential build up and sudden release of ice in the fuel feed system". The build up of ice in the fuel feed system is thought to have occurred when the BA flight from Beijing to Heathrow encountered extremely cold air - as low as -76C - when it flew over Siberia. Because of the restricted fuel flow caused by the ice the engines failed to provide the thrust required and the plane crashed short of the runway at Heathrow. Of the 152 people on board, one suffered a broken leg and 12 others had minor injuries. This was the first crash by a Boeing 777, and there are still over 700 777s in operation. Boeing has given advice to pilots about revising the speed and altitude of flights to try to prevent the same scenario happening again and, like rival aircraft manufacturer Airbus, is also following the AAIB's safety recommendations. "The investigation into the cause of this accident continues. Further testing will be carried out to establish more clearly how ice forms within the fuel system and how it might cause the restricted fuel flows seen on this flight," the AAIB says in its conclusion. No date has yet been announced for the publication of the AAIB's final report into the accident. http://www.holidayextras.co.uk/news/airport/airline-safety-review-ba-heathro w-crash-4625.html ************** Remains of 17 killed in DRC plane crash found UNITED NATIONS, Sept. 4 (Xinhua) -- The United Nations has confirmed that the remains of the 17 people aboard an aid flight which went down in eastern Democratic Republic of the Congo (DRC) Monday have been located in the vicinity of the crash site, according to the news release on the U.N. website Thursday. Seven U.N. staff were among those on the plane which crashed as it was preparing to land in bad weather in the eastern Congolese province of South Kivu. Search and rescue teams located the site of the accident, some 16 km northwest of Bukavu airport. "The process of positive identification of the remains will now be undertaken," U.N. spokesperson Michele Montas told reporters in New York. Alan Doss, the U.N. secretary-general's Special Representative in the DRC, dispatched his deputy, Ross Mountain, to Bukavu to support aid operations and the humanitarian community after the crash. ****** Status: Preliminary Date: 01 SEP 2008 Time: ca 16:00 Type: Beechcraft 1900C-1 Operating for: Air Serv International Leased from: CemAir Registration: ZS-OLD ? C/n / msn: UC-137 First flight: 1990 Engines: 2 Pratt & Whitney Canada PT6A-65B Crew: Fatalities: 2 / Occupants: 2 Passengers: Fatalities: 15 / Occupants: 15 Total: Fatalities: 17 / Occupants: 17 Airplane damage: Destroyed Airplane fate: Written off (damaged beyond repair) Location: 15 km (9.4 mls) NW of Bukavu-Kamenbe (BKY) (Congo (Democratic Republic)) Phase: Approach (APR) Nature: Domestic Non Scheduled Passenger Departure airport: Kisangani Airport (FKI/FZIA), Congo (Democratic Republic) Destination airport: Bukavu-Kamenbe (BKY/FZMA), Congo (Democratic Republic) Narrative: A Beech 1900 operating on behalf of Air Serv International departed Kinshasa on a humanitarian flight to Goma (GOM). En route stops were made in Mbandaka (MDK) and Kisangani (FKI). The last stop before Goma would be Bukavu (BKY), a one hour flight from Kisangani. The airplane approached Bukavu in severe weather. It flew into a steep ridge, some 15 km northwest of Bukavu. The wreckage was spotted the next morning. Unconfirmed reports indicate ZS-OLD was the airplane involved in the accident. The other Beech 1900 used by Air Serv is 5Y-BSP. (aviation-safety.net) *************** EU authorities seek to promote air safety BRUSSELS, Belgium_The Delta Airlines Boeing 767 was cleared for takeoff and started rolling when the pilots spotted a 747 jumbo jet being towed across their runway. They hit the brakes and turned onto an adjacent taxiway. The incident in 1998 at Amsterdam's Schiphol Airport caused only a brief departure delay for the Delta jet. Controllers reported the aborted takeoff _ later determined to have resulted from poor visibility and a misunderstanding of the position of the towing truck by a trainee controller _ and measures were taken to prevent any repeat. But two years later, Dutch prosecutors brought criminal negligence charges against three controllers. Lengthy legal proceedings led to their eventual conviction, although no sentence was imposed and the controllers later returned to their jobs. "The immediate result of that prosecution was that voluntary reporting of safety incidents in the Netherlands broke down overnight, and the number of reports dropped by 50 percent," said Fiona McFadden, a spokeswoman for the European Cockpit Association, a pilots' umbrella group. Analysts say that the prompt identification of errors or hazards and potential or actual incidents are a fundamental element of air safety management. But recent surveys have revealed that in Europe and elsewhere, such incidents are increasingly going unreported because aviation professionals fear prosecution or punishment by management for their supposed mistakes. Currently, automatic prosecution is standard practice in many parts of the world. This practice recently was highlighted in France, where two Americans and three French citizens were charged in connection with the 2000 Concorde crash. In contrast, the United States already has in place a relatively successful Aviation Safety Reporting System. Established in 1975 by NASA, the system collects, analyses and responds to voluntarily submitted but confidential aviation incident reports to reduce accidents and improve safety. The reporting rate is huge _ about 500,000 reports in 30 years _ because NASA databases have until now been protected against prying by legal authorities and employers. But experts say the American model cannot be easily replicated in Europe or other countries with different judicial systems. They also point out that civil lawsuits following an accident are far more common in America than in Europe because of differing legal systems. In response, aviation groups _ including Eurocontrol, the continent's Brussels-based air navigation agency, and the European Cockpit Association _ have launched efforts to protect pilots, controllers, engineers and other operators. The European Commission _ the European Union's head office _ also is in the process of revising its directives on accident investigation to ensure that voluntary reporting of problems does not become tantamount to self-incrimination. "The problem is determining the line between behavior that's not prosecutable _ like the controllers in Amsterdam where there was clearly no negligence _ and truly egregious behavior," said Sydney Drekker, a professor at Sweden's Lund Aviation University. For example, if a pilot makes a hard landing he'll likely be reluctant to report it if he fears that he will be sanctioned. But this could cause damage to the landing gear or airframe, and might adversely affect safety conditions for the next crew flying that plane. The International Civil Aviation Organization, the U.N. agency overseeing civil aviation, is now considering enforcing its recommending that prosecutions and punishments be restricted in order to encourage more open reporting. ICAO will tackle the issue at a key conference in Montreal in October. A draft resolution emphasizes that investigations should not be used for purposes other than accident and incident prevention. It will also address the apparently conflicting goals of finding facts and finding faults in safety-related incidents. Ahead of that meeting, Eurocontrol has taken the lead in formulating the new standards and defining a concept known as Just Culture _ a practice where operators are only punished for gross negligence or willful violations. "Do we want to wait to learn only from disasters themselves, or do we want to learn from lower-level incidents reported to us by front-enders such as pilots, controllers or engineers," said Dragica Stankovic, a safety expert at Eurocontrol. The goal should be to encourage a culture of transparency _ rather than cover-ups _ by allowing employees to freely report occurrences that happened to them or to their colleagues without fear of self-incrimination, Stankovic said. Statistics on non-reporting of incidents are notoriously difficult to come by because of the reluctance of participants to volunteer such information. But an anonymous survey conducted during a European aviation safety workshop in 2006 involving 130 representatives from national regulators, air traffic controllers' groups, pilots' organizations and investigators, found that that 36 percent of respondents feared legal sanctions resulting from national legislation. Another 31 percent were reluctant to report errors mainly due to concerns about the reaction of their company management. Other factors cited included professional pride (12 percent), the complexity of the reporting system (3 percent), the lack of follow-up (8 percent), cultural reasons (6 percent), and even the fear of being exposed in the media (2 percent). "Prosecutors and managers must balance factors for and against prosecution carefully and fairly. A prosecution is less likely to be needed if the offense was committed as a result of a genuine mistake or misunderstanding," said Antonio Licu, safety manager at Eurocontrol. http://callcenterinfo.tmcnet.com/news/2008/09/04/3634125.htm **************** FAA Adds ADS-B Equipment In South Florida Free TIS-B, FIS-B Available To Pilots With Equipped Planes The FAA announced Thursday that pilots flying in aircraft equipped with Automatic Dependent Surveillance-Broadcast (ADS-B) avionics in South Florida now receive free traffic and weather information on their cockpit displays. This marks the first time area pilots are able see the same traffic information that's seen by air traffic controllers. The display of traffic information (called Traffic Information Service-Broadcast, or TIS-B) and weather information (Flight Information Service-Broadcast, or FIS-B) was made possible by the installation of 11 ground stations in South Florida by ITT Corp. The ground stations transmit satellite signals showing aircraft locations to pilots and controllers. Flight information now being broadcast free to pilots includes graphical displays of weather tracked by the National Weather Service and essential flight information, including special-use airspace and temporary flight restrictions. The agency says it's is on track in its aggressive plan to deploy ADS-B nationwide, beginning in Florida. Full commissioning of broadcast services in Florida is scheduled for November. Once commissioning takes place, ground stations will start transmitting as soon they are installed and readied for service. ADS-B ground stations providing both TIS-B and FIS-B services will be deployed along the East and West Coasts, areas of the Midwest and portions of Alaska by 2010. By 2013, ADS-B coverage will be in place everywhere the FAA now provides radar coverage. There will also be coverage in places where radars can't be deployed, such as the Gulf of Mexico. ITT was awarded the national contract to establish the ground infrastructure for ADS-B a year ago. The 11 sites in Southern Florida are at Lakeland Linder Regional Airport, Hardee, Okeechobee, Dade-Collier Airport, Key West, St. Cloud, Sebastian Municipal Airport, Hobe Sound, Boca Raton Airport, Homestead Dade Marina and Florida Keys Marathon Airport. FMI: www.faa.gov aero-news.net ***************